Experience with surgical treatment of prosthetic valve endocarditis

Prosthetic valve endocarditis (PVE) is a rare but dangerous complication that may occur after the implantation. The authors retrospectively summarize their 11-year experience in treating PVE. 2357 prosthetic valve (PV) implantations were performed over 11 years at the Department of Cardiovascular Surgery, Semmelweis University, Budapest, PVE was found to be the indication for operation in 1.8% of the cases (43/2357). 43 surgical interventions were carried out on 38 patients (mean age: 52.5 yrs, male/female ratio: 25/13). Blood cultures were positive in 86% and negative in 14% of the cases. The infected PV-s were replaced emergently (14%), urgently (79%) or electively (7%). The explanted valves were aortic in 55% and mitral 45% of the cases, 63% were mechanical and 37% biological. PVE followed the primary PV implantation in less than a year in 39.5%. Infected environment during the primary PV implantation was found to be a predisposing factor for the late endocarditis episodes. The mean age of the infected and explanted aortic bioprosthetic valves was significantly higher than that of explanted mechanical valves (p < 0.05). No such difference could be found at the mitral valves. The explanted valves were replaced by mechanical (75.5%) or biological (22.5%) devices. Homograft was implanted once. Early postoperative mortality of the primary PV replacements was 10.5%) devices. Homograft was implanted once. Early postoperative mortality of the primary PV replacements was 10.5%. Endocarditis reoccurred in 20% of the cases. Means follow-up duration was 45.5 months. Two-, five- an 10-year survival were 75%, 64% and 51% respectively. In conclusion in the surgical treatment of PVE, bioprosthetic and mechanical valves are suitable alternatives as opposed to homografts and freestyle stentless valves.     

Aortic infectious endocarditis on native valve

Between 1990 and 2002, 32 patients with mean age of 34 years has been treated for an aortic infective endocarditis on native valve. All the patients had recognised heart disease before developing the infection. 24 patients are operated for aortic valve replacement. The hospital mortality was 15.6% (5 patients). The mean follow-up was 47.4 months. The survival rate was 75%. Aortic infective endocarditis remains a serious affection with poor prognosis, despite the contribution of echocardiography and advances in antimicrobial therapy and cardiac surgery. Significants morbidity and mortality are usually caused by sequele of the disease rather than by the infection itself.     

Coexistent congenital aortic defects, aneurysm of sinus of valsalva, atrial septal defect and infective endocarditis: a case report

Coarctation of the Aorta is frequently associated with bicuspid aortic valve. This is a risk factor for infective endocarditis. Aneurysm of a sinus of Valsalva is a rare defect with a prevalence of 0.09%. They are associated in 10% of cases with a bicuspid aortic valve and less frequently with coarctation of the aorta and atrial septal defect. It is extremely rare the association of coarctation of the aorta with an atrial septal defect. This is one of the first cases reported in Puerto Rico of an adult patient with coarctation of the aorta in association with a bicuspid aortic valve, a ruptured aneurysm of a sinus of Valsalva and an atrial septal defect. The patient is a 22 year old male with coarctation of the aorta diagnosed since childhood who was admitted at the Cardiovascular Center of Puerto Rico with signs of heart failure due to infective endocarditis secondary to a teeth infection. Upon evaluation with transthoracic and transesophageal echos, he was found to have a coarctation at the aortic isthmus, aortic root dilatation, bicuspid aortic valve with vegetation, severe aortic and tricuspid regurgitation, aneurysm of the non coronary sinus of Valsalva with perforation to the right atrium, biatrial enlargement and a dilated right ventricle. Successful antibiotic treatment of endocarditis was achieved followed by surgical replacement of the aortic valve and ascending aorta with closure of the non coronary sinus of Valsalva was done. An secundum atrial septal defect was found and was also closed. Surgical correction of the coarctation of the aorta was postponed for a future time. The patient had a successful postsurgical recovery and was discharged home with anticoagulation treatment.     

Screening for Q Fever in Patients Undergoing Transcatheter Aortic Valve Implantation,Israel, June 2018–May 2020

Q fever infective endocarditis frequently mimics degenerative valvular disease. We tested for Coxiella burnettii antibodies in 155 patients in Israel who underwent transcatheter aortic valve implantation. Q fever infective endocarditis was diagnosed and treated in 4 (2.6%) patients; follow-up at a median 12 months after valve implantation indicated preserved prosthetic valvular function.     

Cardiac and vascular homograft valves transplant

The advances in the manipulation of human tissues, the development of cryobiology, paediatric cardiac surgery, the impossibility of obtaining an ideal prosthetic cardiac valve and the surgical treatment of cardiovascular infections have revived interest in the use of homografts. The donors of these homografts can be: a) Live donors: aortic and pulmonary valve of the recipient of a heart transplant; b) Multiorgan donors with a diagnosis of death according to neurological criteria, whose heart is rejected for heart transplant; c) Cadaver donors with asystolia of less than 8 hours. Homograft cardiac valves are the substitute of choice in aortic valve endocarditis, patients with counter-indications for anticoagulation, reconstruction of the outflow tract of the right ventricle, aortic valve replacement in children and young adults through the Ross operation, and an optional indication is the aortic valve and/or rising aorta replacement in patients over 60 years of age. Although there are not sufficiently broad series of homogratfs with arterial substitutes, with respect to the number of patients and time of evolution, the results suggest that this can benefit patients with vascular infection, immunodepressed patients or complex patients whose technique during the operation might require a homograft.     

Doppler echocardiography in the examination of normally functioning artificial mitral and aortic valves

Patients with prosthetic valves were investigated by Doppler echocardiography in 902 cases between November 1987 and February 1990. The parameters of 209 of 344 mitral and 258 of 299 aortic prosthetic valves were evaluated. No significant correlation was found between the type of aortic or mitral prosthetic valves and the measured gradient. As concerns the size of the valve and the measured gradient, a close correlation for aortic valve replacement was detected. For a normally functioning mitral prosthetic valve, a maximum early diastolic velocity of less than 2 m/s (16 mm Hg gradient) and a pressure half-time of less than 130 ms (mitral valve area 1.8 cm2) were characteristic. In cases of aortic valve replacements, the maximum velocity was less than 3 m/s (36 mm Hg gradient), except for the small-diameter valves. More than 95% of the cases met these criteria. (Even if small-diameter valves were included, a maximum velocity of more than 3 m/s occurred only in 8.9%.) Doppler echocardiography is a suitable tool for detecting normal prosthetic valve function, while colour Doppler allows the optimal alignment of jet direction and Doppler beam.     

Role of transoesophageal echocardiography in bacteremia caused by Staphylococcus aureus

Treatment and prognosis of bacteremias caused by Staphylococcus aureus is different, whether only bacteremia is present or it is complicated with endocarditis. Transoesophageal echocardiography may have a role in evaluation of bacteremias caused by Staphylococcus aureus to confirm or exclude infective endocarditis. The aim of this study was to characterize patients with infective endocarditis. PATIENTS AND METHOD: We reviewed the patients studied with transoesophageal echocardiography at our institute between October 1988 and March 2002. The reason for transoesophageal echocardiography was bacteremia caused by Staphylococcus aureus. A total of 24 patients data were analyzed, 15 male and 9 female. Suspicion of infective endocarditis was in 11 patients with native valves, in 8 patients early after prosthetic valve implantation, in 2 patients late after prosthetic valve implantation and in 3 patients after pacemaker implantation. Patient's data were analyzed retrospectively. RESULTS: Thirteen patients had infective endocarditis and 7 of them had community acquired infection. Native valve, prosthetic valve and left ventricular thrombus were the infected tissues. Vegetation was present in 11 patients, one of them was infection of the left ventricular thrombus. Paravalvular leak was found in 3 patients and abscess in 2. Three out of 7 patients with native valve infective endocarditis presented on a structurally normal valve. Eleven patients had no infective endocarditis, in 9 of them there was nosocomial bacteremia. Surgery was performed in 8 patients with infective endocarditis: 3 with acute, 3 with subacute and 2 with late infection. Two patients died after surgery, one of them had acute infection. Four medically treated patients were cured and one died. From the 11 patients without infective endocarditis 7 were cured and 4 died. At the autopsy infective endocarditis was diagnosed in one out of 4 patients. Transoesophageal echocardiography was performed in this patient 4 weeks before death. CONCLUSION: The authors' date suggest, that transoesophageal echocardiography is the diagnostic tool for differentiation between bacteremia and infective endocarditis. The infective endocarditis in both community acquired and nosocomial Staphylococcus aureus bacteremia can cause infective endocarditis on native valves, in thrombus and on intracardiac materials.     

Experience in the care of patients with artificial heart valves

Author reports of 164 cases, 145 of whom received mechanic artificial valves and 19 bioprosthesis. 76 valves were implanted in mitral position, 65 in aorta position, 19 in mitral and aorta position, and 4 valves were localized in other positions. Follow-up was 5.9 years meanly. During care paravalvular insufficiency (11 cases) and infectious endocarditis (9 cases) were observed most frequently. Thromboembolic complications developed in 6 patients, artificial-valve-thrombosis and severe haemorrhage occurred in four cases respectively. During care 32 patients died. This is a 5.4 p.c. mortality. The most frequent causes of death were left-ventricle insufficiency (10) and infectious endocarditis (8). Artificial valve thrombosis and subdural haemorrhage lead to death in three cases respectively. Author discusses anticoagulant treatment and emphasizes the importance of regular control to avoid complications and to discover them at an early stage.     

Clinical prediction rule for 30-day mortality in Björk-Shiley convexo-concave valve replacement

BACKGROUND AND OBJECTIVE: We aimed to develop a clinical prediction rule for 30-day mortality in patients undergoing Bj?rk-Shiley convexo-concave (BScc) valve replacement, based on primary valve implantation procedures. METHODS: We studied 30-day mortality in 2,263 patients who received a BScc valve between 1979 and 1985 in The Netherlands. A logistic regression model was constructed and internally validated with bootstrapping techniques. RESULTS: Predictors for mortality were emergency operation, coronary artery disease, mitral or double-valve replacement, BScc implant being a reoperation, endocarditis, poor left ventricular function, age, concomitant tricuspid valve plasty, and aortic root replacement. The area under the receiver operating characteristic curve (AUC) for the predicted probability of death was 0.76 (95% CI 0.72-0.80). The model calibrated well, and had adequate discriminative ability in 195 BScc valve patients who underwent explantation, including 53 prophylactic explantations (AUC 0.81, 95% CI 0.73-0.89). CONCLUSION: A prediction rule derived from BScc valve implantation data performed well in patients undergoing explantation. Because the model provides accurate individualized estimates of the risk of mortality after reoperation, it may be helpful for decision making in patients with BScc valves.     

Protein C,S and antithrombin III levels in patients with acute mechanical valve thrombosis

BACKGROUND: Mechanical prosthetic heart valve thrombosis is a serious complication with an incidence of 1-6%. The reduction in active vitamin-K dependent protein C and S levels caused by warfarin treatment also results in a prothrombotic state. This study was conducted to investigate the connection between protein C (PC), protein S (PS), antithrombin III (ATIII) deficiency and prosthetic mechanical valve thrombosis. METHODS: Twenty-nine of the 283 patients who underwent valve replacement with St. Jude medical prosthesis had mechanical valve thrombosis (group 2). The rest were considered as group 1. Twelve of the 29 patients (41.4%) had isolated aortic valve replacement, 12 had isolated mitral valve replacement (41.4%) and 5 patients had double valve replacement (17.2%). Most of the patients had rheumatic valve disease at their 1st operation. The mean time of occurrence for mechanical valve occlusion was 4.1+/-1.0 years following surgery. RESULTS: The values of PC, PS and ATIII were obtained when the mechanical valves stuck or at routine follow-up. PC, PS and ATIII levels were significantly lower in the mechanical valve thrombosis group. PC levels were 75.4+/-37.6% and 49.9+/-32.2% in group 1 and 2, respectively (p=0.001). PC, PS and ATIII values were mostly lower in the 2nd group but this difference only became significant after at least 2 years of warfarin usage. CONCLUSIONS: Natural anticoagulant levels can be low during the use of warfarin. In which case the dose can be increased in order to hold the international normalized ratio (INR) at 3-3.5. However, more frequent follow-up is required and patients should be investigated for hypercoagulation states or deficiency in anticoagulant proteins. Patients referred to hospital with any mechanical valve thrombosis or recurrent thromboembolism should be evaluated for hypercoagulant proteins.     

Methicillin resistance and risk factors for embolism in Staphylococcus aureus infective endocarditis.

OBJECTIVE: Infective endocarditis caused by Staphylococcus aureus is an ominous prognosis associated with a high prevalence of embolic episodes and neurological involvement. Whether methicillin resistance decreases the risk of embolism in infective endocarditis is unclear. We sought to assess the association between methicillin resistance and risk factors for embolism in S. aureus infective endocarditis. DESIGN: Retrospective chart review. Data from patients with infective endocarditis due to methicillin-resistant S. aureus were compared with data from patients with endocarditis due to methicillin-susceptible S. aureus. Logistic regression was used to identify independent risk factors for embolism. SETTING: A 2,000-bed, university-affiliated tertiary care hospital. PATIENTS: Between 1995 and 2005, 123 patients with S. aureus infective endocarditis were included in the study. There were 74 male patients and 49 female patients, with a median age of 54 years (range, 0-89 years). RESULTS: Of 123 infections, 30 (24%) were nosocomial infections, and 14 (11%) were prosthetic valve infections. Of 123 S. aureus isolates, 48 (39%) were methicillin resistant. In total, embolism occurred in 45 (37%) of these patients: pulmonary embolism in 22 (18%), cerebral embolism in 21 (17%), and peripheral embolism in 6 (5%). The independent risk factors for an embolism were injection drug use, presence of a cardiac vegetation with a size of 10 mm or greater, and absence of nosocomial infection. For 83 patients with aortic or mitral infective endocarditis, independent risk factors for an embolism were the presence of a cardiac vegetation with a size of 10 mm or greater and endocarditis due to methicillin-susceptible S. aureus. Overall, in-hospital death occurred for 32 (26%) of 123 patients. Methicillin-resistant infection was not an independent risk factor for death. CONCLUSIONS: Methicillin-resistant S. aureus infection was associated with decreased risk of embolism in left-side endocarditis, but was not associated with in-hospital death.     

Porcine bioprosthetic aortic valve endocarditis with ring abscess and aortic stenosis

Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis with Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder.     

主动脉瓣感染性心内膜炎瓣膜置换术后远期效果

 目的 探讨自体主动脉瓣单独受累感染性心内膜炎（IE）对外科主动脉瓣置换术（SAVR）远期预后的影响。方法 回顾性分析2013年1月—2017年12月在首都医科大学附属北京安贞医院行SAVR的自体主动脉瓣单独受累IE患者的病历资料，同时采用倾向性评分匹配（PSM）非IE对照组患者，对所有入组患者进行长期随访，观察术后生存率及并发症累积发生风险，中位随访时间为69个月。结果 共纳入2 821例患者，其中IE SAVR患者143例（IE组），非IE的SAVR患者2 678例（对照组）。IE组患者长期生存率低于非IE配对对照组，差异有统计学意义（P=0.044）。IE患者SAVR手术后更容易发生缺血性脑卒中事件，差异有统计学意义（P=0.035），且缺血性脑卒中事件为影响患者生存的独立危险因素（P=0.014），发生缺血性脑卒中患者的死亡风险更高（HR=2.811；95%CI：1.233~6.408）。IE组患者大出血累积发生率和主动脉瓣再手术率与非IE配对对照组比较，差异均无统计学意义（均P>0.05），且均不是影响患者生存的独立危险因素（均P>0.05）。结论 与非IE对照组患者相比，自体主动脉瓣单独受累IE患者行SAVR后发生死亡、缺血性卒中的风险更高。应加强对IE患者行SAVR后的密切随访，重点预防脑卒中等并发症。     

Risk factors for nosocomial infective endocarditis in patients with methicillin-resistant Staphylococcus aureus bacteremia.

BACKGROUND AND OBJECTIVE: Nosocomial infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are increasing. Only a few studies of MRSA infective endocarditis have been conducted, and none have reported its risk factors. We sought to determine the host-related risk factors for infective endocarditis in patients with nosocomial MRSA bacteremia. SETTING: A 2,000-bed, university-affiliated, tertiary-care hospital. PATIENTS: Thirty-one patients with nosocomial MRSA infective endocarditis between October 1996 and May 2003. DESIGN: A retrospective chart review was conducted. Data were compared with those from a control group of patients with nosocomial MRSA bacteremia. Logistic regression was used to identify independent risk factors for nosocomial infective endocarditis. RESULTS: Compared with patients who had nosocomial MRSA bacteremia and no infective endocarditis, patients who had infective endocarditis had a higher incidence of chronic liver disease and a lower incidence of immunodeficiency. The risk of developing infective endocarditis was approximately 10% for patients with nosocomial MRSA bacteremia. CONCLUSION: Patients with MRSA bacteremia and underlying chronic liver disease were prone to infective endocarditis.     

成年人小主动脉瓣环者机械瓣膜置换术后远期疗效

目的 探讨成年人小主动脉瓣环者机械瓣膜置换术后的远期疗效,以指导临床实践.方法 2003年7月至2005年2月对36例小主动脉瓣环(直径≤19mm)的成年患者行人工机械瓣膜置换术.分别采用改良Manougnian法瓣环扩大后植入23 mm CarboMedics机械瓣膜14例(CM组);瓣环上主动脉瓣置换法直接植入19 mm CarboMedics Top Hat Supra-Annular Aortic机械瓣膜22例(CMSA组),于术前和术后6年评价两组患者的心功能,超声心动图检测左心室舒张末内径(LVDD)、室间隔厚度(IVST)、左心室后壁厚度(LVPWT)、收缩期主动脉瓣平均跨瓣压差(PGav)、左心室短轴缩短率(LVFS),计算左心室射血分数.并抽取20例健康成年人的超声心动图数据作为对照组,对三组资料进行对比分析.结果 术后6年与术前比较,除CMSA组的IVST[(10.37±2.06)mm比(11.03±2.45)mm]和LVPWT[(10.53±2.18)mm比(11.24±3.09)mm]差异无统计学意义外,CMSA组的心功能分级、LVDD、PGav、LVEF、LVFS和CM组的全部检测指标均较术前有不同程度改·善(P＜ 0.01或＜0.05).术后6年CM组的PGav较CMSA组下降更明显[(9.24±5.93)mm Hg(1mmHg=0.133 kPa)比(24.30±12.50)mmHg],差异有统计学意义(P＜ 0.05);CM组术后6年各项指标与对照组比较差异无统计学意义,而CMSA组的IVST、LVPWT、PGav与对照组比较差异仍有统计学意义(P＜0.05).结论 成年人小主动脉瓣环者机械瓣膜置换术后远期左心室功能多恢复良好,但行瓣环扩大术应植入较大内径的瓣膜,将有利于左心室形态的逆转.     

Cases of infective endocarditis caused by Campylobacter fetus

An 18-year-old man with infective endocarditis caused by Campylobacter fetus is reported. This bacterial species has long been of interest in veterinary medicine, and recently it has been reported to be one cause of infantile diarrhea. Infective endocarditis arising from campylobacter fetus is rare. This is the fourth case reported in Japan. The organism was resistant to several antibiotics, and large vegetations were found to involve the aortic valve. Emergency excision of the infected aortic valve and replacement with a valve prosthesis were successful. Current clinical treatment of infective endocarditis is discussed, and the literature briefly reviewed.     

复发性真菌性心内膜炎1例及文献复习

56岁的女性患者,因"反复乏力、纳差、发热1年余,再发2个月并突发左侧肢体抽动10 d"入院。2017年患者被确诊为感染性心内膜炎后行主动脉瓣置换术,瓣膜活检示近平滑假丝酵母菌,术后患者规律服药,连续3次血培养阴性后停药。2018年患者再次出现发热并发多器官梗死,血培养再次分离出近平滑假丝酵母菌。提示真菌性心内膜炎可在人体内长期潜伏、复发,赘生物脱落可栓塞各个器官导致相应的临床表现,手术联合药物治疗以及后续维持抗真菌治疗对改善患者的预后极其重要。     

心脏人工瓣膜术后真菌性心内膜炎2例报告及治疗策略文献综述

目的探讨心脏人工瓣膜置换术后真菌性心内膜炎的治疗策略。方法对2例心脏人工瓣膜术后并发严重真菌感染病例进行回顾性分析,并进行相关文献复习。结果 2例患者术后并发真菌性心内膜炎,均影响瓣膜功能,术后均反复住院,病例一,心脏术后45 d出现发热,返院复诊,予以急诊在体外循环下行再次二尖瓣置换术,术后赘生物培养为黄曲霉菌;病例二,心脏术后5个月在体外循环下行主动脉壁赘生物清除,术后赘生物病理提示毛霉菌。2例患者均及时手术清除感染灶并进行规范抗真菌治疗,曲霉菌感染患者抢救无效,毛霉菌感染患者治愈,后者抗真菌治疗强度更大。结论心脏人工瓣膜置换术后并发真菌性心内膜炎,预防是关键,治疗要及时、有效,抗真菌药物必须足量、足疗程。     

血培养阴性感染性心内膜炎的临床特点

 目的 探讨血培养阴性感染性心内膜炎的临床特点及手术治疗效果。方法 收集某院心胸外科2014年1月—2021年12月经手术治疗的感染性心内膜炎患者的临床资料,按血培养病原学结果分为阳性组、阴性组,回顾性分析两组患者的临床特点及外科手术效果。结果 共有88例感染性心内膜炎患者,血培养阴性61例(阴性组),阳性27例(阳性组),阳性率为30.7%。83例患者术前超声心动图有阳性发现,包括赘生物、瓣膜毁损、人工瓣瓣周漏、脓肿、腱索断裂等,所有患者均经外科手术治疗。阴性组患者发热的比率较阳性组低(36.1% VS 81.5%),胸闷气促的比率较阳性组高(80.3% VS 74.1%),差异均有统计学意义(均P＜0.05)。61例阴性组患者的基础心脏病以合并主动脉瓣二叶畸形为主(16.4%);累及主动脉瓣(37例)、二尖瓣(20例)、三尖瓣(2例),2例同时累及主动脉和二尖瓣;阴性组患者瓣膜毁损(78.7% VS 63.0%)和腱索断裂(47.5% VS 22.2%)比率较阳性组高,差异均有统计学意义(均P＜0.05)。两组患者均以心功能不全及栓塞为主要并发症,心功能不全者阴性组18例,发生率29.5%,阳性组7例,发生率25.9%。阴性组患者病死率为8.2%,阳性组为7.4%,两组比较差异无统计学意义(P＞0.05)。结论 早期诊断、早期规范治疗,选择合适的手术时机和方案,以及加强围手术期管理,血培养阴性感染性心内膜炎患者可取得较好的治疗效果。     

Development and results of valve replacement surgery at the Városmajor Clinic 1976-1990 (retorospective clinical analysis)]

In Hungary valve replacement is still a major indication for heart surgery in adults. In the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest from 1976 to 1990 2435 patients were operated for valve disease. Majority of the cases had single (aortic n = 856, mitral n = 912) or double (aortic + mitral n = 513) valve replacement. Over this 15 years period there have been many alterations in patients characteristics and surgical technique as well. In spite of the increasing mean age of patients the operative mortality has decreased (in the last 5 years period it was 2.7%, 5.5% and 7.9% in the three groups respectively). At the same time the number of patients requiring valve re-replacement or combined valve + coronary procedure has increased. The use of bioprosthetic valves has fallen below 10 percent from the 60--80 percent observed between 1976--1980. The analysis showes excellent surgical results in the field of valve replacement in Hungary.